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For all the controversy surrounding health care policy these days, one key idea is so widely accepted across the political spectrum that it has almost become a cliché: we need more primary care doctors. Patients complain of the difficulty of getting an appointment, primary care physicians report overwhelming patient volume, and workforce projections depict a sobering, widening gap between future need and future supply of primary care doctors. To be sure, an influx of primary care doctors alone won’t bend the cost curve or suddenly improve population health. But without more primary care doctors, our health care system will continue to struggle to take care of an increasingly old and unhealthy population.

As a first-year medical student trying to figure out my future specialty, I’m living this issue. And whenever I mention primary care to other medical students, the specific response varies widely but the general reaction is always the same: wistful cuteness. Oh, primary care is so great, they say; we need more primary care doctors. Then they tilt their heads and give me a sweet, encouraging smile. Their responses remind me of how my college friends who are now management consultants react to my other college friends who are now in AmeriCorps.

Why this reaction to primary care? The main turnoff is obvious: a specialist can out-earn a primary care doctor by millions of dollars over a lifetime. However, I think there’s a bigger issue at play. As medical students, our self-identity is very much wrapped up in our professional future. Starting with our pre-medical studies, we are used to sacrificing personal and family time for the privilege of patient care and thus come to consider our work very much part of ourselves. We want our peers, then, to respect us for our career goals. And in medical-student-speak, “interest in neurosurgery” translates into “I am smart, tough, courageous, and will be the master of my operating room.” If I tell someone I am interested in neurosurgery, people turn their heads, intrigued. On the other hand, “interest in primary care” translates into “I am willing to be overworked, underpaid, and underappreciated because I want to treat patients in a holistic way”—and results in cute head-tilts and sweet half-smiles. We don’t like that. For the price of the same medical degree, we rather have higher social currency and have heads turn.

The way to increase primary care physician supply is simple: increase salaries. The Affordable Care Act made a step in the right direction. We also need to simplify billing, continue to incentivize the spread of health information technology, develop better communication between primary care doctors and specialists, and fix the many other issues that (rightly so) drive primary care doctors crazy. But beyond that, the social currency of primary care among medical students also needs to be dramatically raised. Teach for America (TFA) made an entire generation of top college students excited about teaching, not because TFA has increased teachers’ salaries or fundamentally changed the scope or practice of teaching. Rather, its primary achievement is convincing Ivy League college students that teaching in underserved school districts is reserved for tough, smart leaders who want to change the world. So college students began respecting TFA members and, in turn, wanting to join them. A similar transformation needs to take place for primary care among medical schools across the United States.

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Ken Kelly

I think you are dead on. I think a lot of this has to do with perception. While increasing salaries for primary care providers certainly helps it is important that we start looking at certain specialties in a different light.

Medical School fails to teach medical economics. It would be a threat to the social hierarchy of professors on fixed salaries if the truth about capitated, risk based, risk adjusted, fairly shared net rewards, closed panel, negotiated prices, health care organizations were known.

In fact it would be a threat to the entire health reform industry. Maybe being threatened is the reason I get so little respect when I elaborate on this as I have in several places including
Humana's stock aol discussion board.

Maybe the academic cadre is not as dispassionate as they sometimes have portrayed themselves. I never thought of social currency; too much a iconclastic loner to care long about it.
But social pressure may isolate an important factor in other's motivation..

My little panel of 130 HMO patients garners a risk based allocation of $110,000 a month.The capitation is an additional $70 per member per month. All the figures are available from the source; get back to me if you are interested.

And on the other side, the fee for service side, I know some family docs who are doing fabulously- though working hard also I'm sure.

They don't teach medical economics because departments of medical economics are staffed by theoreticians like Regina Hertzberger and think tanks like Commonwealth Fund are dedicated to the aggregate instead of helping individuals out smart the system.

After reading 14 books on my shelf and many white papers on the subject I think the only way to learn the field is to do it. The books are not well informed on this one topic. They dwell on the past aggregate. They will not tell you how to be better than average And they disregard an individual's intelligence, drive, and integrity. They apply hard economic motivation instead of your reality, being interested in primary care.

Only you can size yourself up against your medical class peers. Can you stand your ground when unnecessary tests and procedures are proposed? Do you live to be praised? Or do you live to be right and good? Can you finesse a hand? Can you win at chess swooping in for the mate before the person on the other side can defend?

Know yourself then consider primary care/ internal medicine.

Max Romano

Thanks so much for the enlightening article, Chris. I'm a first year med student at Hopkins who is interested in primary care also, and my med school has a pretty dismal track record for producing primary care docs. As an AmeriCorps alum, I see what you mean with TFA making teaching 'sexy' to recent college grads, however I doubt TFA will influence social perceptions of career teachers as much as widespread educator benefit cuts will. I fear we're still a long way off from recognizing real value with our health care dollars, but it's a goal I look forward to working towards.

Doctors for America is a national movement of physicians and medical students working together
to improve the health of the nation and to ensure that everyone has access to affordable,
high quality health care.